Citation Nr: 21030964 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 12-29 149 DATE: May 20, 2021 REMANDED Entitlement to service connection for dermatomyositis, to include as due to exposure to anthrax vaccine, is remanded. REASONS FOR REMAND The Veteran had active military service from November 1983 to November 1986 and June 1987 to May 1992. The Veteran died in March 2013. See July 2014 Death Certificate. The appellant is the Veteran's surviving spouse and has been properly substituted in this case. See March 2017 Correspondence. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The appellant testified before the undersigned Veterans Law Judge at a videoconference hearing in May 2018. By way of background, in June 2018, January 2020, and November 2020, the Board remanded the issue on appeal for further evidentiary development. The Board finds that additional remand is required to the Agency of Original Jurisdiction (AOJ), as the medical opinion from the VA examiner is incomplete. Entitlement to service connection for dermatomyositis, to include as due to exposure to anthrax vaccine, is remanded. A review of the records shows that in a July 2012 VA treatment record the Veteran was diagnosed with dermatomyositis. See January 2012 CAPRI and October 2012 CAPRI. The records confirm that the Veteran's dermatomyositis affected the lung and vocal cord. See October 2012 CAPRI. Additionally, in an October 2012 VA treatment record, it was noted that the Veteran had dermatomyositis with different pattern of weakness distally in hands atypical for diabetes mellitus and more likely due to effort limited by pain. See May 2019 CAPRI. A review of the service treatment records (STRs) shows that in a November 1986 STR, the Veteran complained of having shortness of breath at rest. See August 2016 STR Medical. In an August 1987 STR, the Veteran was noted to have multiple cherry angioma on his back and chest. In a March 1988 STR, the Veteran was again noted to have cherry angioma on his back and chest. In an August 1991 STR, the Veteran had rash on his groin and legs and was diagnosed with tinea cruris. In a January 1992 STR, the Veteran complained of itchiness around his right shoulder area in the back. On examination, there was an area of redness on his chest. It was noted that it was a possible codeine allergy. The STRs also show that in December 1987 the Veteran complained of weight loss. However, the records show that the Veteran's weight fluctuated with a gradual increase from 187 pounds to 208 pounds. The STRs do not show any complaints of regurgitation or fatigue. In a July 1992 VA treatment record, the Veteran exhibited decreased grip on his right arm and rash on his legs. He was diagnosed with tinea/candida rash. See August 1992 Medical Treatment Record Government Facility. In an August 1992 VA treatment record, the Veteran was noted to have numbness and loss of feeling in his bilateral hands and loss of strength. In the October 2011 VA examination, the examiner diagnosed the Veteran with dermatomyositis and opined that the Veteran's condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the rash identified during service is different from the rash diagnosed at present time which is one of the pathognomic feature of dermatomyositis. In the April 2019 VA addendum opinion, the same examiner opined that the Veteran's dermatomyositis is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran's in-service rash was allergy related and was treated with Benadryl and tinea cruris was resolved with antifungal cream. However, the rash diagnosed in October 2011 was dermatomyositis. In the February 2020 VA addendum opinion, the same examiner opined that the Veteran's dermatomyositis is less likely as not caused by or related to his military service, specifically due to his in-service anthrax vaccine. The examiner explained that dermatomyositis is an idiopathic inflammatory condition characterized by autoimmunity and inflammatory involvement of the muscle fibers (i.e., myositis) resulting in muscle weakness. A review of medical literature did not reveal definitive association between anthrax vaccine and dermatomyositis. In the November 2020 VA addendum opinion, based on a review of the Board's November 2020 decision, medical opinion from February 2020, service treatment records, and medical literature, the examiner opined that the Veteran's diagnosed dermatomyositis is less likely as not caused by or related to his military service, specifically due to his in service anthrax vaccine. The examiner explained that the Veteran had unremarkable general examination (i.e., no skin rashes, no weight loss, or muscle weakness) in the August 1992 separation examination. The Board finds that a remand is warranted as the examiner did not consider the STRs as a whole. For instance, in an August 1987 STR, the Veteran was noted to have multiple cherry angioma on his back and chest. In a March 1988 STR, the Veteran was again noted to have cherry angioma on his back and chest. In a January 1992 STR, the Veteran complained of itchiness around his right shoulder area in the back and on examination there was an area of redness on his chest. Shortly thereafter, the Veteran had decreased grip of his right arm and had numbness and loss of strength in his bilateral arms. Although the Veteran was not diagnosed with dermatomyositis until 2011, the Veteran had red rash on his legs, chest, and back and moreover the Veteran had loss of strength in his arms which was later attributed to his dermatomyositis. Of note, a July 2012 VA treatment record, a doctor in rheumatology noted that "it should be considered that his autoimmune condition may be related to his vaccines." See October 2012 CAPRI. As it is unclear whether the examiner considered all the symptoms in a holistic manner, the Board finds that a remand is warranted. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's dermatomyositis. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that dermatomyositis had its onset in service or is otherwise etiologically related to service, to include as a result of receiving the anthrax vaccine. The examiner is asked to consider that in an August 1987 STR, the Veteran was noted to have multiple cherry angioma on his back and chest. In a March 1988 STR, the Veteran was again noted to have cherry angioma on his back and chest. In a January 1992 STR, the Veteran complained of itchiness around his right shoulder area in the back. On examination, there was an area of redness on his chest. Shortly thereafter, the Veteran had decreased grip of his right arm and had numbness and loss of strength in his bilateral arms. Although the Veteran was not diagnosed with dermatomyositis until 2011, the Veteran had red rash on his legs, chest, and back and moreover the Veteran had loss of strength in his arms which was later attributed to his dermatomyositis. See May 2019 CAPRI. The examiner should also consider that in a July 2012 VA treatment record, a doctor in rheumatology noted that "it should be considered that his autoimmune condition may be related to his vaccines." See October 2012 CAPRI. A detailed rationale for all opinions must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.